Chronic pain in the interweb

It’s not very often that I’m moved to respond to other blogposts about chronic pain. When I go onto Google and search for chronic pain SO many awful, quacky, misleading sites come up, promising this and that with so little evidence to support their claims, I’ve tended to avoid looking. Today, however, thanks to the Neuroscience and Pain Science for Manual Physical Therapists group on Facebook (go Diane!) I was lead to the ever-challenging Science-Based Medicine blog in which a review of the book The Pain Chronicles by Melanie Thernstrom is posted.

Now I have not read The Pain Chronicles (by all accounts it looks like a fascinating read), but one of the statements cited in SBM’s review is one of the more profound comments about the management of chronic pain that it bears repeating:

“Medical treatment of pain is suboptimal because most doctors have not yet incorporated recent scientific discoveries into their thinking, discoveries indicating that chronic pain is a disease in its own right, a state of pathological pain sensitivity.”

I don’t intend to enter the debate as to whether chronic pain should be called a ‘disease’ in its own right (I do think that’s partly semantics, partly funding opportunities), it’s much more important to me to point out that chronic pain is a ‘state of pathological pain sensitivity’.

“Why is that important?” you ask. Well, because there is a cohort of medical (and allied health clinicians too) who continue to believe that much of chronic pain is nociceptive and if ‘the source of the pain’ is found and removed, the pain also goes. Things return to normal. And this group of practitioners support this notion by citing the success of joint replacements where immediate pain reduction is obtained.

Well – maybe things are not quite as clear-cut as all this. An fMRI study of people with OA hip showed that along with the changes expected from short-term pain, there were also changes indicative of central sensitisation. There are a good proportion of people having joint replacements who continue to have pain despite the wonderful new joint. People having had diagnostic blocks indicating facet joint nociception proceed to radiofrequency neurotomy but fail to respond with the pain vanishing. And thinking that simply removing nociceptive input will prevent an individual from processing that experience and learning from it (as well as their family and friends responding to them) is just daft.

It seems to me that if we can have pathology in almost every body system (trying hard here to think of a single body system that doesn’t have pathology!) then it’s highly likely we can also have a dysfunctional nociceptive system. In other words, a nervous system that can also not function well. And clearly, it’s not just the peripheral parts of the nervous system that get involved with chronic pain, it’s also central processing – and this includes multiple areas in the brain, not just this vague ‘sensory cortex’ that so many of the neurology of pain processing diagrams show. Those parts of the brain are about memory, emotion, alertness, attention, decision-making – where does pain processing actually stop?

Chronic pain is complicated. It involves multiple body systems, involves the psychology of an individual – and as I’ve often pointed out on here, it also involves social aspects of being human. So it pains me (no pun intended) to see promulgation of some rather strange and magical thinking about the origins of chronic pain. One of those is the belief that psychological trauma, especially trauma and/or emotions that are ‘repressed’, directly causes pain. I quote from SBM “Dr. John Sarno believes that chronic musculoskeletal pain is a manifestation of “tension myositis syndrome” due to repressed negative emotions.”

I don’t want to take on the might of the quite large group of people who are fervent believers of Sarno’s approach which, in it’s main thrust, involves “… renouncing all treatments, accepting that pain is only in the mind, and resuming normal activities.” The latter part (emphasised by me) is what I endorse wholeheartedly. But I do take issue with the belief that psychological ‘trauma’ or ‘repressed emotions’ directly cause pain.

I do this because I have yet to see scientific studies demonstrating this, and I also worry that (1) people can be mislabelled as psychologically unwell (2) people can be asked to ‘find’ and recall ‘repressed’ trauma/emotions (3) I haven’t yet found evidence that catharsis of ‘repressed emotions’ is helpful and (4) resuming normal activities takes a whole lot more than just saying it. The theory/hypothesis doesn’t seem to have been formally tested – although the treatment (ie stopping medical treatment, starting to live more normally) forms part of the basis of CBT approach to pain management. Living normally isn’t easy – it takes skills, changing habits, acceptance – and all those wonderful things that I warble on about in here!

This comment by “wertys” also clarifies the idea of myositis:

““Tension Myositis Syndrome” is not a myositis (muscle inflammation) due to tension (whether mental or physical) and the term is entirely unsatisfactory. What his work does provide is a reasonable stab at trying to link the mental experience of consciousness with some more concrete physiological events that can result in widespread pain. It’s a good try but does fall well short of the current state of the art view of chronic pain and its mechanisms.“

Reading the rest of the comments on this post on SBM is an enlightening experience – and one reason I love the internet/web 2.0 as a forum for scientific writing. Read and judge for yourself!

One of the main reasons I try NOT to get involved in discussions about things I find on the internet is that there are an army of proponents of one treatment or another, and the ‘discussions’ are rarely about sharing viewpoints and being open to new ways of looking at things – instead they become doctrinaire flame wars, and seriously, I can’t be bothered with them. I know this runs the risk of being drowned out, or thought of as afraid of debate, and this I most certainly am not! I hope instead that the evidence base for what I discuss on this blog stands the test of time, because one thing that distinguishes science from dogma is the preparedness of science to revise its standpoint on the basis of evidence. Dogma, on the other hand, seems to produce arguments suggesting that the scientific model itself is wrong, or the premises of the dogmatic view ‘can’t’ be tested using ordinary scientific means.

Doing a search on chronic pain on any search engine, including MedLine or PsychInfo or Google or Bing will give you so many more results than one individual can possibly examine. Amongst the dross there are some gems, and the way to check their utility and veracity? For me, it’s about the use and reference to peer-reviewed research, and the open declaration of what is and is not opinion. This at least means that readers can decide, from the basic research, whether they’re prepared to alter their opinion or accept the commentary.

Chronic pain management needs to involve appreciating the biopsychosocial model, and at least to me, seems to need biomedical, biophysical, psychological, social, and straight-out functional approaches to help people learn to live well despite their pain. Because until pain CAN be abolished, people need to and want to LIVE, not just be patient. Pun most definitely intended.

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3 comments

Hi Bronnie,
I am interested in your take on the responsible* use of pain medication, long term, for people in chronic pain IF they are actually doing everything else possible to manage their pain and lead a normal life. I mean really working out, actually going out and having something that resembles a social life, and refusing to allow the pain to stop you, even if it increases your pain later. I have been getting the “continued use increases your sensitivity to pain”, which I think is silly since I have severe sciatica, fibromyalgia, and I am 9 months post spinal fusion. I quit 40 mgs of oxycontin in 5 days, and now only take percocet, 5-10 mgs ,when I am ready to chew my leg off.
What is your take on meds WITH all attempts to lead a normal life in place? I’d know you are not a doctor, and this is NOT medical advice. I understand if you are unwilling to answer due to ethical concerns.

Warmest regards,
Yvonne

*responsible= lowest dose possible to reduce, not remove pain, combined with medication breaks of at least 1-2 weeks, 1 to 2 times a year, to keep the minimum dose effective.

Hi Yvonne, You’re right – I’m no medical person! At the same time I do work in an interdisciplinary pain management centre and I can discuss the approach used here. It’s going to take more space than a ‘comment’ can allow, so I’ll write a blog post on it, to give the topic the attention it deserves.

In brief, though, medication is one of a range of strategies that can be effective in the long-term management of chronic pain. Most medications have a relatively small effect on pain intensity (estimated at around 30% pain reduction), and don’t directly affect disability. Side effects, tolerance and the long process of getting to a medication regime that is helpful also complicate medication use. There is evidence of opioid-induced hyperalgesia, which is a ‘wind-up’ of pain associated with the use of opioids – and this may be what you’ve been told about.

Having said this, medication has its place in pain management. We routinely incorporate medication use as part of an interdisciplinary pain management plan. It needs to be considered in the same way as medication for something like diabetes – it can help, but needs to be used appropriately, and integrated with other things in the same way that diabetics can’t just rely on medications but also need to eat appropriately, manage stress, exercise and so on.

As I said, a topic for a future blog post, and food for thought.
Thanks for raising it!
cheers
Bronnie

I am beyond frustrated with my doctor. My history shows NO abuse, appropriate increase in doses (only when my pain became so severe I begged for a spinal fusion and when that fusion didn’t resolve my severe, chronic sciatica) and voluntary cessation of the big drugs, such as Methadone, Morphine and Oxycontin.

I currently take Percocet, 40 mgs a day is the maximum I am allowed, and I wait till the pain is in the 6, on a scale of 1 (least) to 10 (most), before I even take medication. This is not working well, my pain is not managed, I am just able to hide it a little better from those around me. I have to force myself to do the things I need to do to live a semi-productive life, and even now, my pain, and the issues it causes, are still not taken seriously.

I just read an American study, that quoted a Danish study, about addiction and pain medication abuse, and I almost laughed out loud! Did the Americans look at the social issues in Scandinavian societies before they chose that source? I think NOT. If one wants to slant an article to a certain bias, one can find ways to do it. Had they chosen the Fishbain, Rosomoff, and Rosomoff paper of 1992: Drug abuse, dependence, and addiction in chronic pain patients, they may have had a quite different slant.

I look forward to reading everything you write, but this is a very important issue to so many of us, so I thank you for taking the time to address it.